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Public Economics,

Evidence Use in Congress: Options for Charting a New Direction; Volume 2

Lawmakers in Congress have expressed a growing interest in the promise of evidence-based policymaking. Bipartisan legislation has been pursued in Congress that would encourage the use of evidence to improve outcomes for key education, health, workforce, and other federal programs. These past legislative initiatives suggest growing potential for the wider use of evidence to better inform congressional decision-making in the future. However, key challenges remain for fostering a stronger culture of evidence in Congress. This stronger culture will be necessary to fully realize the potential benefits of evidence-based policymaking

Improving Opportunities for Working People With Disabilities

In the late 1990's Congress recognized that federal policy not only established low expectations for people with disabilities to live and work independently, but also that the Medicaid program created disincentives for those with disabilities who wished to work. Congress, along with the Clinton administration, enacted laws creating two optional Medicaid eligibility groups through section 4733 of the Balanced Budget Act (BBA) of 1997 and Section 201 of the Ticket to Work and Work Incentives Improvement Act (TWWIA) of 1999.While Medicaid is the primary source of health insurance for people with disabilities, the program provides much more than health care services. Medicaid allows individuals with disabilities to live independently in the community. In addition to health services, Medicaid covers case management services, transportation, specialized medical equipment and supplies, and home and community-based services—including personal care assistant services—among other services not covered by Medicare or private health insurance. BBA and TWWIIA provided additional flexibility for states to offer Medicaid coverage to higher income working individuals with disabilities who—excluding income—meet the Social Security definition of disability. Together, these programs are referred to as Medicaid Buy-in (MBI) for Workers with Disabilities. Separate and distinct from recently implemented Medicaid Community Engagement Demonstrations with work-requirements, the Medicaid Buy-in eligibility option allows workers with disabilities access to Medicaid community-based services not available through other insurers.Over the last year, the Bipartisan Policy Center has identified recommendations to improve availability of the MBI for workers with disabilities. As part of that effort, BPC reached out to stakeholders and hosted public and private discussions with experts on the topic. Participants included current and former state and federal officials, consumers, and other experts. Based on those discussions, BPC developed recommendations to improve Medicaid Buy-in programs for working people with disabilities

Achieving Behavioral Health Care Integration in Rural America

Integrating primary care services and treatment for mental health and substance use conditions not only enhances patients' access to needed care but also improves health outcomes in a cost-effective way. Yet the barriers to integrated care are substantial, and it is even more difficult to achieve in rural and frontier communities, which are home to 1 in 7 Americans.Our current work focuses on breaking down the barriers to integration in rural America, where the health care infrastructure and provider composition vary in distinct ways from urban and suburban areas. Americans in rural areas face significant shortages of psychiatrists, psychologists, clinical social workers, and other behavioral health specialists. More than 60% of nonmetropolitan counties lack a psychiatrist, and almost half of nonmetropolitan counties do not have a psychologist, compared with 27% and 19% of urban counties, respectively. These gaps in specialty care force rural residents to rely heavily on primary providers for much of their care

Next Steps: Improving the Medicaid Buy-in for Workers with Disabilities

The Bipartisan Policy Center's Health Program is building on its previous report, Improving Opportunities for Working People with Disabilities (January 2021), to address barriers to employment for Medicaid beneficiaries with disabilities who often rely on Medicaid's unique services, such as home and community-based services (HCBS), to live independently in the community and work.The Medicaid Buy-In (MBI) for Workers with Disabilities refers to three eligibility groups within Medicaid that allow states to cover working individuals with disabilities who, excluding earned income, generally meet Social Security's definition of disability. The MBI for Workers with Disabilities therefore allows individuals with disabilities to work and retain their Medicaid coverage, or to use their Medicaid coverage to access wraparound services that are not covered under employer-sponsored insurance or Medicare. Enrollment in the MBI for Workers with Disabilities eligibility groups is associated with increased employment and earnings, while also having a positive impact on the economy, state Medicaid agencies, employers, and state and federal governments.In this report, BPC identifies federal policy reforms that will encourage more states to cover or optimize their coverage of the MBI for Workers with Disabilities eligibility groups. These reforms will improve access to the MBI for Workers with Disabilities programs and, thus, allow more Medicaid beneficiaries with disabilities to work and achieve their employment potential. More specifically, BPC has identified a set of federal policy recommendations that Congress and the administration should advance. These federal policy reforms will clarify existing flexibilities that states can adopt when designing their MBI for Workers with Disabilities programs while also strengthening outreach, data, and interagency coordination.

Changes in work habits of lifeguards in relation to Florida red tide

Author Posting. © The Author(s), 2010. This is the author's version of the work. It is posted here by permission of Elsevier B.V. for personal use, not for redistribution. The definitive version was published in Harmful Algae 9 (2010): 419-425, doi:10.1016/j.hal.2010.02.005.The marine dinoflagellate, Karenia brevis, is responsible for Florida red tides. Brevetoxins, the neurotoxins produced by K. brevis blooms, can cause fish kills, contaminate shellfish, and lead to respiratory illness in humans. Although several studies have assessed different economic impacts from Florida red tide blooms, no studies to date have considered the impact on beach lifeguard work performance. Sarasota County experiences frequent Florida red tides and staffs lifeguards at its beaches 365 days a year. This study examined lifeguard attendance records during the time periods of March 1 to September 30 in 2004 (no bloom) and March 1 to September 30 in 2005 (bloom). The lifeguard attendance data demonstrated statistically significant absenteeism during a Florida red tide bloom. The potential economic costs resulting from red tide blooms were comprised of both lifeguard absenteeism and presenteeism. Our estimate of the costs of absenteeism due to the 2005 red tide in Sarasota County is about $3,000. On average, the capitalized costs of lifeguard absenteeism in Sarasota County may be on the order of$100,000 at Sarasota County beaches alone. When surveyed, lifeguards reported not only that they experienced adverse health effects of exposure to Florida red tide but also that their attentiveness and abilities to take preventative actions decrease when they worked during a bloom, implying presenteeism effects. The costs of presenteeism, which imply increased risks to beachgoers, arguably could exceed those of absenteeism by an order of magnitude. Due to the lack of data, however, we are unable to provide credible estimates of the costs of presenteeism or the potential increased risks to bathers.This research was supported by the National Science Foundation under The Research Experience for Undergraduate Program, grant number 0453955; the P01 ES 10594, DHHS NIH of the National Institute of Environmental Health Sciences; the Center for Oceans and Human Health at the Woods Hole Oceanographic Institution [National Science Foundation (NSF) OCE-0430724; National Institute of Environmental Health Sciences (NIEHS) P50 ES012742]; and the Ocean and Human Health Center at the University of Miami Rosenstiel School (NSF 0CE0432368; NIEHS 1 P50 ES12736)

Adapting without retreating : responses to shoreline change on an inlet-associated coastal beach

Author Posting. © The Author(s), 2017. This is the author's version of the work. It is posted here under a nonexclusive, irrevocable, paid-up, worldwide license granted to WHOI. It is made available for personal use, not for redistribution. The definitive version was published in Coastal Management 45 (2017): 360-383, doi:10.1080/08920753.2017.1345607.Coastal barrier systems around the world are experiencing higher rates of flooding and shoreline erosion. Property owners on barriers have made significant financial investments in physical protections that shield their nearby properties from these hazards, constituting a type of adaptation to shoreline change. Factors that contribute to adaptation on Plum Island, a developed beach and dune system on the North Shore of Massachusetts, are investigated here. Plum Island experiences patterns of shoreline change that may be representative of many inlet-associated beaches, encompassing an equivocal and dynamically shifting mix of erosion and accretion. In the face of episodic floods and fleeting erosive events, and driven by a combination of strong northeast storms and cycles of erosion and accretion, the value of the average Plum Island residence increases by 34% for properties on the oceanfront where protection comprises a publicly constructed soft structure. Even in the face of state policies that ostensibly discourage physical protection as a means of adaptation, coastal communities face significant political and financial pressures to maintain existing protective structures or to allow contiguous groups of property owners to build new ones through collective action. These factors mitigate against adapting to shoreline change by retreating from the coast, thereby potentially increasing the adverse effects of coastal hazards.Support for this study was provided by NSF Grant Nos. OCE 1325430 and AGS 1518503 and NOAA Cooperative Agreement No. NA14OAR4170074

Public Health Forward: Modernizing the U.S. Public Health System

Public Health Forward: Modernizing the U.S. Public Health System defines a vision for a modernized public health system in the 21st century and provides a framework of practical, prioritized, and bipartisan actions for policymakers and public health officials to guide strategic investments and decision-making to help translate the vision into a reality with a focus on equity. The federal government continues to provide critical leadership and funding to navigate the current pandemic and has a responsibility to make significant investments and changes in public health for the post-pandemic future. Long-term, increased, sustainable funding and policy leadership from the federal government will be crucial to support this five-year vision, framework, and set of actions, as most public health departments are concerned over their funding levels, notwithstanding the recent infusion of money

A cluster randomized trial to reduce HIV risk from outside partnerships in Zambian HIV-Negative couples using a novel behavioral intervention, "Strengthening Our Vows": Study protocol and baseline data.

BACKGROUND: Heterosexual couples contribute to most new HIV infections in areas of generalized HIV epidemics in sub-Saharan Africa. After Couples' Voluntary HIV Counseling and Testing (CVCT), heterosexual concordant HIV negative couples (CNC) in cohabiting unions contribute to approximately 47% of residual new infections in couples. These infections are attributed to concurrent sexual partners, a key driver of the HIV epidemic in Zambia. METHODS/DESIGN: Ten Zambian government clinics in two of the largest cities were randomized in matched pairs to a Strengthening Our Vows (SOV) intervention or a Good Health Package (GHP) comparison arm. SOV addressed preventing HIV infection from concurrent partners and protecting spouses after exposures outside the relationship. GHP focused on handwashing; water chlorination; household deworming; and screening for hypertension, diabetes and schistosomiasis. CNC were referred from CVCT services in government clinics. Follow-up includes post-intervention questionnaires and outcome assessments through 60 months. Longitudinal outcomes of interest include self-report and laboratory markers of condomless sex with outside partners and reported sexual agreements. We present baseline characteristics and factors associated with study arm and reported risk using descriptive statistics. RESULTS: The mean age of men was 32 and 26 for women. On average, couples cohabited for 6 years and had 2 children. Baseline analyses demonstrated some failures of randomization by study arm which will be considered in future primary analyses of longitudinal data. An HIV/STI risk factor composite was not different in the two study arms. Almost one-quarter of couples had an HIV risk factor at baseline. DISCUSSION: In preparation for future biomedical and behavioral interventions in sub-Saharan Africa, it is critical to understand and decrease HIV risk within CNC